Thrive explores the new effective solutions to the misery and injustice caused by mental illness. It describes how successful psychological treatments have been developed and explains what works best for whom. It also urges us to do all we can to prevent these problems in the first place, through better schools and a better society. Marion Koob reviews, writing that this is a crucial and necessary book, especially for those who know little about mental illness.
Thrive: The Power of Evidence-Based Psychological Therapies. Richard Layard and David M. Clark. Penguin. 2014.
Mental illness is a hidden blight. Neglected throughout the world, it is an endless source of discrimination. While the majority of its sufferers go untreated, those that do ultimately get medical care receive it after year-long delays, or are handed inappropriate treatments.
This is why Thrive, by Richard Layard and David M. Clark, is a crucial and necessary book. The authors give a chilling overview of the paucity of mental healthcare in the western world. Focusing on depression, anxiety disorders and conduct disorders in children, they seek to persuade their readers of their widespread extent, and of the effectiveness of existing solutions.
Layard is a prominent labour economist, member of the House Lords, and author of the book Happiness. Clark is Professor of Psychology at Oxford, and is a world expert on Cognitive Behavioural Therapy.
These ailments appear to be effectively treated with psychological therapies. However, Layard and Clark argue that many are unaware of the the wide range of evidence-based therapy now available. The authors go on to demonstrate that improved provision of therapy is not only a humanitarian imperative: it also makes economic sense. The book includes an evaluation of the United Kingdom’s Improved Access to Psychological Therapies (IAPT), which began in 2008 (the authors lobbied for its implementation). Thrive concludes with suggestions as to which societal behaviours and aspirations could prevent the prevalence of mental illness and be conducive to a happier population.
Thrive is very much an advocacy book seeking to effect policy change. In this respect its release is timely; distant enough from IAPT’s beginnings to offer an evaluation, and published ahead of the 2015 UK General Elections. The issue has generated some attention in the media, whether in the form of petitions or comment pieces. What’s more, the authors present new inroads into diseases which were previously difficult to treat.
Compared to physical illnesses, mental disorders are woefully under-treated, principally thanks to the lack of suitable psychological therapy. In Chapter 4, entitled Do they get help?, Layard and Clark note that while 90 per cent of people with diabetes are supplied with healthcare, in the UK, US and continental Europe, less than a third of those with mental illness are treated. In low and middle income countries, this drops below 10 per cent. In the US, two-thirds of primary care physicians say they cannot get outpatient services for people with mental health problems, while in the UK, only 15 per cent of GPs who responded said that they could obtain the adult services they need.
Worse, in the US, people who do ultimately receive care for their mental health issues face incomprehensible delays in accessing it. On average, this translates to a wait of sixteen years for social phobia; nine for generalised anxiety; and eight for depression. Only 28 per cent of suicides in Britain had been in contact with mental services during the previous twelve months.
Instead of therapy, individuals are offered pills. As medication is more readily available, and is used to treat other diseases, it is better understood. What’s more, medication is produced by drug companies, who are effective lobbyists. In contrast, there is no forceful lobby for psychological therapy. Unlike most physical troubles, mental illness is a subject of stigma. Victims and their families are more likely to be ashamed and thus less insistent that the doctor find a solution. Misperceptions regarding available treatments contribute to this, as many people believe that mental illness is untreatable. When the public believes there is no solution, Layard and Clark argue, issues tend to be avoided, thus reinforcing the victims’ shame.
Who then is to blame? Clark and Layard decry those who fund the provision of psychological therapy, that is to say, the commissioners of the National Health Service in the UK, or in the US and many other countries, the rules of insurers.
In Chapter 11, Can we afford more therapy?, the authors go on to assert the cost efficiency of providing adequate treatment. ‘Can we afford it?’, budget-anxious politicians and administrators alike will ask. With mental healthcare, investing in further provision would cost nothing. Yet, they remark that this question isn’t considered when it comes down to physical illnesses.
Investing in psychological therapies, would, the authors argue, generate large savings in welfare. Unlike physical illness, mental illness is a problem of people in their working age. Treating sufferers on unemployment benefits could give them the ability to successfully job search. According to modest estimates, which are backed up with exact numbers, providing such care would generate savings by putting people back in employment. There exists previous evidence of this: in a randomised trial with a sample size of 300, 34 per cent of those who received a given CBT treatment (over seven weeks, in three hour long sessions) were back in employment after four months. Out of those who had received generalised sessions of social support, only 13 per cent had found a job.
The second source of savings would come from physical healthcare. Those with mental health problems generate more costs in physical healthcare than those with comparable diseases. People with chronic physical illness account for 70 per cent of all healthcare costs in Britain, and those of them who are mentally ill cost some 50 per cent more than other patients with the same physical condition and at the same level of severity.
Here, evidence also suggests that these savings could be significant. In 1997, Britain’s national centre for angina, a coronary heart disease, introduced a short behavioural programme. It consisted of two 2-hour interviews eight weeks apart, with two consultants, plus stress-management advice, relaxation tapes, self-help manuals and graded exercise. In the year after taking this programme, patients spent 33 per cent fewer days in hospital than the year before, fewer of them died, and the total saving in cost per patient was £2,000. Layard and Clark underline that similar results in savings to pay for treatments have since then occurred through the IAPT.
Throughout the book, Layard and Clark posit an effective and well-backed case for the need of further psychological therapy, and a change of mindset regarding mental health.
However, the book suffers from a few minor flaws. While its economic argument is persuasive, it is a worrying reflection of our society that it should need to be made in the first place. If we aim to come to regard mental illness as equally grave and deserving of attention as physical illness, does justifying on the basis of a low cost not risk being detrimental? Layard and Clark are responding to the realities of policy-making when arguing their case, but it seems like their humanitarian argument should have been at least as equally fleshed out as that of the economic.
In addition, the book’s focus on building a case allows the authors to set aside unanswered questions. It would have been interesting, for instance, to hear their thoughts as to why the success rates of the best therapies are only 50-60 per cent, or why provision of effective care has lagged so far behind the time of its initial discovery.
Finally, Thrive also lets its readers down with the production of its graphics, most of which are either not labelled clearly or understandable. For a work seeking to persuade through force of evidence, it is rather frustrating to not be able to check the authors’ arguments against the tables which they reference.
In the last chapters of the book, Layard and Clark maintain that a society focused on improving relationships and creating happiness, rather than increasing GDP and income, would better thrive. It is a radical change from the current mindset, and when reading the numbers one can’t help but think that they’re likely right. Their book is an important work, and would be valuable for anyone to read, especially those who know little about mental health.
Marion Koob has a BSc in Government and Economics at the LSE and and MPhil in International Relations at the University of Cambridge. She has worked in Polis, the LSE’s journalism think-tank, and is now at the British Film Institute.
Authors David M. Clark and Richard Layard gave a public lecture about their book at the LSE; you can listen here.